Medications, Injections and Other Treatments for Knee Osteoarthritis
Understanding other treatments that may be used alongside core treatments
Medications, injections and some other treatments may be useful for some peoplewith knee osteoarthritis (i.e., not everyone will need them). Multiple add-on (or second-line) treatments exist. But, regardless of choice, they should always be used alongside the core recommended treatments and never replace them (i.e. you need to continue to engage with education, exercise and weight management).
There also may be some cross-over with some self-management. For example, use of assistive devices or a cold pack may be part of your self-management routine.
Medications
There are no treatment options that can reverse the osteoarthritis process, including medications. Therefore, people with knee osteoarthritis who use medications do so to help control their symptoms. Remember – medications shouldn’t be used as a standalone treatment but instead should be used in conjunction with core recommended treatments such as exercise and self-management. They should also not be considered a long-term solution.
Which medications are prescribed for osteoarthritis?
Anti-inflammatories (for example ibuprofen, diclofenac and naproxen) probably show the most promise for controlling symptoms for people with knee osteoarthritis.
There are two types – oral (medications you swallow) or topical (for example creams).
Anti-inflammatory gels or creams that are rubbed directly on to the knee are generally advised before oral anti-inflammatories as they are safer.
This is because anti-inflammatories in pill form are not suitable for everyone. People who also have other medical conditions like gastrointestinal (stomach) or heart conditions are not recommended to use them.
You should always check with your GP or pharmacist whether anti-inflammatory medications are suitable for you.
Paracetamol used to be a common medication provided to people with knee osteoarthritis to help control symptoms.
HOWEVER improvements in pain are very small and have not been found to be clinically effective in scientific trials. For example, they often do not work better than a placebo.
There is also emerging evidence to suggest that paracetamol is linked to a number of side effects (for example gastrointestinal issues).
Opioids (for example tramadol). These are strong prescribed pain relievers.
They are generally not recommended for people with knee osteoarthritis as the harms outweighs any benefit. For example, harms include increased frequency of dizziness, risks of falls and fractures compared to anti-inflammatories, plus can lead to addiction, overdose and dependency issues.
Ask First
Always ask your doctor what medication may be right for you.
Limit Usage
Limit your medication use to managing short-term flare ups
Safety Matters
Understand the risks and side effects before taking medications.
If I start taking medications, does that mean I have to continue taking them?
NO!!
It is important to remember that medications are add-on treatments. Some people with knee osteoarthritis may need to use medications in the short-term to help manage their symptoms, however over time as you learn more about the condition, causes of symptoms, improve your self-management skills and get fitter and stronger, the reliance on medications should decrease.
It’s also important to consider the medications pyramid. Generally, you want to take the least toxic form of medication that works for you (e.g. start at the bottom and work your way up if necessary).
Another important thing to consider is that it is possible to move down the medications pyramid as well as up. For example, if you have a particularly bad time with symptoms and need to take ibuprofen, you are not “stuck” at this level. The next time you need medications, you can try using a topical gel.
It is important that you discuss any medications with your GP or pharmacist.
Injections
Where possible, people should attempt to manage their symptoms with core recommended treatments and topical or oral medications before considering injections. Information in this section has been created to provide you with information about the various options.
What injection options are available for people with osteoarthritis?
The main injection options, alongside some key information about each are provided below:
Cortisone injections
- These are powerful anti-inflammatories and therefore have similar risks to those of topical or oral anti-inflammatories.
- Often performed using ultrasound or x-ray to guide the injection into the knee joint.
- They may provide some pain-relief, however their effects are generally short-lived (6-12 weeks).
- They have not shown any meaningful benefit beyond placebo (salt injection) for knee osteoarthritis.
- There is some research to suggest that repeated injections actually accelerate the condition of osteoarthritis.
- At least 3 months should elapse between a corticosteroid injection and any knee surgery due to an increased risk of infection.
Hyaluronic acid injections
- Currently these injections are not recommended for knee osteoarthritis.
- These injections aim to restore the ‘natural fluid’ within the joint, however they do not appear effective at doing this in the long-term.
- They also usually only result in short-term temporary pain relief and perform no better than a placebo injection.
Platelet-rich plasma (PRP) injections
- Most medical guidelines recommend against the use of PRP due to their limited effectiveness and issues around ‘how’ they are performed.
- They aim to regenerate tissues within the joint however research has not yet determined if they are successful in doing this.
- Research has produced mixed results on their ability to improve pain and perform no better than a placebo injection.
Stem cell injections
- Medical guidelines recommend against their use due to safety and concerns about methods in which they are performed.
- There is also a lack of evidence to support their use from high-quality trials.
How do I know if I need an injection?
There is no simple answer to this question. The decision to have an injection should be extensively discussed between you and your healthcare practitioner including the benefits and risks of receiving it. Remember that you should attempt to manage your symptoms with core recommended treatments and topical or oral medications before considering injections. It is also important to remember that injections are not long-term solutions to your symptom control.
Is it possible to avoid needing an injection?
YES!!!
Injections are only suitable for ‘some’ people with knee osteoarthritis. Additionally, their effectiveness can be short-lived.
Are exercises and other core treatments needed after an injection?
YES!!!
Injections tend to only offer temporary symptom relief. In the long-term, the best options available for your knee osteoarthritis are the core treatments mentioned in this website. Click here to revisit the core treatments page and learn more (or refresh your memory) on the topic.
Other Treatments for Knee Osteoarthritis
There are many other treatments that some people find helpful for osteoarthritis. It is important to note that none of these treatments are likely to provide you with long-term pain relief or a cure but you may get some short-term pain relief, particularly when combined with the core recommended treatments. The other factor to consider is the cost of these treatments (if any) and whether this outweighs the benefits.
Click on the images below to take you to the treatment that you want to find more information on.
HOT OR COLD
Heat packs and ice packs have been used throughout time to help with different types of body discomfort. However, many people with knee osteoarthritis are unsure whether they should be using it for their knee.
Does it make a difference which one I choose?
NOT REALLY!
Both ice packs and heat packs can provide some temporary relief of symptoms. Ice packs or cooling devices tend to be used after surgery. But most people with knee osteoarthritis prefer heat to ice packs as a long-term symptom management approach.
How long should I apply it for?
It is generally advised to apply heat or ice for no more than 20 minutes, and to wrap it in something first (e.g. light cloth) to avoid burns (note it is possible to get heat and ice burns!). It is therefore especially important that you don’t fall asleep whilst you have heat or ice packs on your knee.
Are there any risks with hot or cold?
There is a risk of heat or ice burns, therefore it is important that you:
- Have good sensation in the knee before applying the heat or ice pack.
- Test the temperature before applying.
- Wrap the heat or ice pack in something (e.g. clean tea towel)
- Avoid placing over uncovered wounds, broken skin, rashes etc.
- Do not leave on for longer than 20 minutes.
- Check with your GP if you have any other reason why you shouldn’t use heat or ice.
ASSISTIVE DEVICES
Many people with knee osteoarthritis use assistive devices as part of their overall self-management. Assistive devices are walking equipment that are used to help with movement or reduce pain during movement. Some people will use devices all the time (e.g. using a walking stick regularly), and some people will only occasionally rely on devices (e.g. using walking poles for hiking).
How do I know if I need a walking stick or walking poles?
There is no exact answer to this. In general, a walking stick is recommended if you feel unsteady on your feet, or if you walk with a limp. Some people will need a walking stick all the time and others may need it for longer walks or for periods where symptoms are flared-up. Temporarily using a walking stick enables you to move in a more “natural” way, reducing unusual stress and strain on your body. As your symptoms improve while using the walking stick, you often find you can do more and walk longer distances.
Walking sticks, canes, crutches or Nordic walking poles are all examples of types of aids you can use. People usually use walking poles to assist them on longer hikes or on particularly uneven ground. Nordic walking poles are a great way to burn more calories on longer walks too! You work harder but walking feels easier – which is great!
If you have any queries about whether you need a device to help your walking, then speak to your healthcare professional (e.g. physiotherapist or occupational therapist) for advice. Click here to go to our Patient Resources page, where you can find a healthcare professional or a walking group in your region, such as Sports Partnerships or Nordic walking programmes (Fit Walk Ireland).
Tips for using a walking stick
- Hold it on the opposite side to the knee that causes you the most issues. For example, if your right knee is painful, you should hold the stick in your left side. This way, every time you take weight onto the painful leg, you can take some weight through the stick too.
- Measure the stick height with your normal shoes on. Standing with your arm by your side, the top of the handle of the walking stick should come to the same level as the crease of your wrist.
- Check the rubber (ferrule) on the bottom of your stick has not worn smooth or split.
- Always move the stick forward first with the weak or painful leg, then your other leg.
- Where possible go up and down the stairs normally, holding on to the handrail. Step up first with your less painful leg and bring the other leg up to meet it (and the stick if you are using one). Going down the stairs is opposite – lead with the more painful leg and stick, follow with the less painful leg.
Check out this video for more tips on using a walking stick:
MASSAGE AND MANUAL TREATMENTS
Conflicting advice exists about the use of massage and manual treatments in clinical practice guidelines for people with knee osteoarthritis. Some recommend it and some recommend against it. The most important thing to take note of is that even the guidelines that recommend it only suggest its use as an add-on (adjunct) to core treatments of education and self-management, exercise and physical activity, and weight management.
What is the difference between massage and manual treatments?
Many people think that massage and manual therapies are the same thing, but although they have similar effects, they are slightly different.
Massage usually involves touch and techniques applied to the whole leg with the aim of promoting relaxation and having an impact upon lymphatic drainage. The exact mechanisms of why people can feel better after massage are unclear, however it is probably mainly due to relaxation.
Manual therapies can contain a number of different options that are usually performed by healthcare professionals. Generally, manual therapies are more targeted approaches that are performed in an attempt to improve mobility or alter symptoms. Just like massage, the exact mechanisms of why people can feel better after manual therapies are unclear. A large proportion of the treatment effect is likely due to a change in how your body and mind react to movements or symptoms.
Unfortunately – both of these treatments have short-lasting effects. Therefore, they are only considered for some people to compliment core treatments and should not be seen as a long term solution or something that can ‘fix’ osteoarthritis.
Is massage and manual therapy safe for osteoarthritis?
Yes, generally speaking, massage and manual therapies are safe for people with knee osteoarthritis. However, it is important to consider the effectiveness when making a decision about seeking these treatments.
PRESCRIBED FOOTWEAR AND ORTHOSES
Many people with knee osteoarthritis use prescribed shoes or orthoses (also known as insoles) to help manage their condition.
Is wearing certain shoes or insoles good for my osteoarthritis?
Some people with knee osteoarthritis respond very well to footwear and insoles. From a broader perspective – there is some evidence to indicate that supportive shoes can reduce pain and improve function in the medium term (roughly 6 months). BUT – for supportive footwear to be effective they need to be worn for between 7.5-8.5 hours per day!
If you are interested to find out if more supportive shoes may help you, we recommend you seek specialist advice from a podiatrist.
Are there any types of shoes I should be avoiding?
Unsupportive sandals and high heels can often cause discomfort for people with knee osteoarthritis. If you have any queries about your own footwear, we recommend that you speak with a podiatrist.
Are there any negatives with trying different shoes for my osteoarthritis?
Sometimes wearing certain footwear can cause a temporary increase in pain or reduction in function. Usually this is nothing to worry about and should resolve within a few days. Review our “understanding symptoms” page and scroll down to the section titled “What should I do if my symptoms flare-up?” to learn how to manage your symptoms if this happens.
Who is the best person to speak to about shoes or insoles for my osteoarthritis?
SUPPLEMENTS
Supplements are sometimes used by people with knee osteoarthritis with varying results. The information here provides you with some basic information about common or promising supplements.
What is a supplement?
Broadly speaking, supplements are substances that may be considered foods, or parts of foods, that are taken by an individual for medical or health benefits.
The most commonly investigated supplements for people with knee osteoarthritis include glucosamine and chondroitin. These are compounds extracted from animal products and are considered to improve cartilage health.
Are supplements useful for the management of osteoarthritis?
Well respected research generally suggests that there is minimal or no benefit of taking supplements to improve pain or function for people with knee osteoarthritis.
That being said, supplements are generally safe for people with knee osteoarthritis to take, and some people do report positive outcomes. Therefore, the decision to trial supplements should be one that is discussed between yourself and your healthcare professional (e.g. GP, Rheumatologist or Pharmacist).
Which supplements are commonly used for osteoarthritis?
The following supplements are commonly used. However, most medical guidelines now recommend against their use.
- Glucosamine
- Chondroitin
- Omega-3
- Vitamin D
- Turmeric
The reason to advise against their use is that widespread research has failed to find them beneficial in studies with large numbers of people.